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Cigna's Lake Wobegon Wellness Guarantee: Everyone Gets Better

Intelligent Design Awards are lovingly bestowed upon those contributions to the population health field that most set back the evolution of outcomes measurement, thanks to a unique and usually hilarious combination of dishonesty and cluelessness. But there is a serious lesson here: Engineers say that more is learned from a single bridge which collapses than from 100 which stay up. The good news is, that means there is not just a lesson here but an entire curriculum, because as it turns out, every bridge in wellness falls down. Yes, every single wellness outcome which has been made public is made up.

In Cigna’s Well Aware wellness program guarantee calculation, no one ever gets sicker.

Their wellness offering guarantees that 30% of high- and medium-risk people will subsequently become low-risk. However, they don't offset this 30% with the number of low-risk people who subsequently become medium- or high-risk...and about twice as many people are low-risk to begin with, according to Cigna.

What is the significance of twice as many people being low-risk to begin with? It means that if 15% of low-risk people gain weight, get stressed, stop exercising, fall off the wagon or resume smoking, the entire 30% risk reduction in the higher-risk people is negated.

But Cigna isn’t counting that 15% in their guarantee. Just the 30%. According to Cigna’s guarantee math, no one ever gets worse.

Watch what happens when you apply Cigna’s math to the real world.

Suppose smoking is the only risk factor. Further suppose that, while all employees smoke sometimes, all employees also quit sometimes. A-L smokes in even-numbered years and quits in odd-numbered years. M-Z quits in even-numbered years and smokes in odd-numbered years. Cigna's methodology would show 100% success every year...even though the rate of smoking remains the same every year.

And, by the way, Cigna’s methodology does not take into account that some people (in this hypothetical, all of them) reduce their risk factors on their own, rather than waiting for a wellness program.

Fact is, people do migrate between risk levels, and often do it on their own, as anyone who has tried to quit smoking/drinking, or lose weight will confirm.

Could this be an innocent mistake on Cigna's part? Could their actuaries really not understand that people's risk scores can change? Look at the three segments in each bar on p 2 in their wellness brochure, and then you decide. Note that even though the first rule of bar graphs is that the segments are drawn to scale, the segments of each bar are all drawn the exact same size, even though there are far more low-risk people than high/medium risk. A skeptic might say: "The reason they don't draw the segments to scale is because if they did, even the densest consultant might notice that there are so many low-risk members that at least a few of them might increase their risk."

But at least one consultant noticed, and he is looking forward to the day when they change their guarantee and/or rewrite their brochure, and he can write a press release bragging how a single consultant taught basic arithmetic to the country’s fourth-largest insurance company. Because while in Cigna’s world risk factors only improve, throughout the disease management and wellness industries, absent DMPC intervention, outcomes methodologies only get worse.